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Post-Election Analysis: Healthcare Financing for Healthy Homes Services Still Hard, Still Possible, Still Important

Two days after the recent presidential election I had to make a decision. I was supposed to be getting on a plane to California so that I could give a talk about opportunities to finance healthy homes services through the healthcare sector. This is a presentation I have given many times. I think and talk about this subject every day (yes, even weekends, #PublicHealthNerd). But I found myself at a loss for what to say. My hesitation wasn’t even a commentary on the outcome of the election but rather a reaction to the plain fact that, regardless of whether the idea thrilled or repulsed me, our healthcare system might be about to undergo another radical transformation.

The word “might” in that sentence is important. Because it is the uncertainty of what the scale and nature of that transformation could look like that made me wonder why I should fly across the country to stand in front of a room full of people and pretend that I had any answers about how to navigate this new reality. About how we would continue our work to ensure and expand access to critical public health services like home-based asthma and lead poisoning follow-up services.

But then I remembered. I remembered three things.

First, I wasn’t going to this meeting for a one-way exchange. I always leave meetings like that with new knowledge and inspiration, and I was obviously in need of both.

Second, I started working on this issue back in 2005 when I was a research scientist with the New York State Department of Health, under such an unfavorable environmental health policy landscape that my supervisor at the time begged me not to throw away my young career on something that was, in her opinion, so fruitless and so fringe. True story.

Third, I ignored her advice and discovered that there were others already working at the fringe to expand access to preventive environmental health services through the healthcare sector. In fact, some of you had been there so long, you’d taken up permanent residence. And you welcomed me in, shared your stories, your strategies, your successes and failures. And as a result, I started to work. In those early years, that meant laying the groundwork for change that would come later. I learned as much as I could about different program models, about Medicaid and healthcare financing. I talked to absolutely everyone and anyone who had tried or even thought about trying anything remotely like what I was trying to do. I wrote policy proposals about once a quarter for four years, failing repeatedly to gain any traction but always listening to what fell short and using that information to sharpen my pitch and improve my approach. I led a team that invited the state Medicaid agency, a local health department home visiting program, and four Medicaid managed care plans to help design a pilot program that wasn’t aimed at adding to the evidence base that we could improve health outcomes and reduce costs but instead focused on answering their questions and concerns about how such a program could operate in the real world. And what happened is that we answered those questions, we did improve health outcomes, we did save money; and in 2011 when New York State’s Medicaid Redesign Team was looking for ideas for how to improve healthcare delivery in the state, they came to us to ask for a proposal to fund home-based asthma services (and other healthy homes services) through the Medicaid program. That proposal was recommended and endorsed by the Health Disparities Workgroup of the Medicaid Redesign effort, subsequently included in New York State’s approved mega-waiver application to the Centers for Medicare and Medicaid Services, and will ultimately be implemented by seven Performing Provider Systems across the state that are financed through a funding pool that is reinvesting $6.5 billion of the savings previous reforms generated for the federal program back into public health prevention initiatives, including home-based asthma services.

And by this point in the conversation with myself, I was on a roll. I reminded myself that as part of my work at the national level I already know that there are many ways to get this work financed and that many, if not most, of them predate the Affordable Care Act (ACA). I reminded myself that when we cross-tabbed the results of our nationwide survey of state Medicaid policies for home-based asthma and lead-poisoning follow-up services with states that had adopted Medicaid expansion, we found no pattern whatsoever. I reminded myself that the American Lung Association’s more recent map of coverage of home-based asthma services shows progress in both red and blue states and that the most recent state to join the ranks of those providing coverage of home-based asthma services was Missouri. Coverage of environmental health services can have bipartisan support.

Now, I’m not saying that the ACA hasn’t been important or relevant to this work. It is. It’s opened up some new opportunities, it’s meant that there were more people insured to benefit from the policies we put in place through the healthcare sector, and it has sparked a genuine interest from the healthcare sector in figuring out how to address social determinants of health, like housing, and how to shift costs from treating chronic diseases to preventing them. It’s meant there was momentum and enthusiasm to put these types of services and programs in place. So it has been important. But it hasn’t been everything. Because underneath that there was a foundation. There was a foundation made up of health plans like Priority Health in Michigan and the Monroe Plan for Medical Care in upstate New York who in the late 1990s and early 2000s were already investing in these services. And of community-based organizations, like the Asthma Network of West Michigan, who were ready to partner with them and tell the rest of us the secret to getting the job done. And of state- and local-funded initiatives, including the New York State Healthy Neighborhoods Program, which has operated continuously since 1985 reaching 7,500 homes or more every single year. And of ordinary people like me in red and blue states across the country who were busy laying the groundwork. And of the staff who designed the Asthma Community Network to help us find each other and the best practices we needed to get our work off the ground.

And here’s the thing: That foundation still exists, and it is stronger now than it has ever been. We have more examples than ever of how financing these services isn’t just good healthcare, it’s good business. We have good reason to believe that the value of this work will continue resonate across the political spectrum and evolving healthcare landscape. And we have a bigger army of ambassadors to carry that message for us.

So regardless of what happens next, we can always do those two things. We can look for the forward thinkers, the Priority Healths and the Monroe Plans, in each state or community, and in places where there aren’t any, we can shore up the foundation so that when the landscape changes again and the conditions are more favorable, we can be ready to transform these systems permanently. 

In the end, I got on the plane. I got back to work.

A few days later the Centers for Medicaid and Medicare Services announced their approval of a State Plan Amendment to use federal and state funding to expand lead abatement activities in the impacted areas of Flint and other areas of Michigan. And I remembered two more things. This work is not only possible, it’s imperative.

Note: Interested in putting home-based asthma services or lead poisoning follow-up services in place, but not sure where to start? Whether you’re a community-based organization, healthcare payer, healthcare provider, public health agency, or housing organization, NCHH and its network of partners can help. Contact for more information or check out our new state-specific case studies and other resources in our Healthcare Financing Resource Library.

Stand Up and Be Counted in the Fight Against Lead Poisoning

Lead poisoning—you know, it seems like we should’ve had this problem licked by now.

Every year, we (NCHH and our partners) get out and stomp the figurative pavement, reminding people—parents, teachers, doctors, members of Congress, the President—that lead is still a very real and dangerous problem. And every year, despite our best efforts, more kids are exposed to lead. This year, we heard of a city (Flint, Michigan) that was exposed to dangerous levels of lead in its water.

All of this despite the fact we’ve known lead was poisonous for over 100 years and despite the fact that lead-based paint was banned in the U.S. back in 1978. That's nearly 40 years ago. The banning of lead-based paint in homes was a major victory, but the war rages on: While no new lead-based paint is being manufactured for residential use here in the United States, lead is still being used in other types of paint. Meanwhile, the lead-based paint that exists in older homes continues to disintegrate into poisonous dust. Lead exposure also comes from aging pipes entering homes and schools, from soil, and in consumer products.

According to Dr. David Jacobs, NCHH's Chief Scientist, "Lead is […] one of the best studied toxic substances that we know of. It’s one of the metals that you don’t need in your body; it has no useful biological value whatsoever. It creates a range of effects [including] neurodevelopmental effects for children at an early age, but it also causes cancer, kidney disease, and many other adverse health effects."

Today, there are still over 500,000 children with elevated blood lead levels in the U.S. Untold numbers of adults—possibly in the millions—struggle daily with the lifelong consequences of their own childhood lead exposure: decreased IQ and cognitive function, developmental delays, and behavioral problems. It’s both unfortunate and unacceptable for any child to be harmed by lead exposure, yet it continues to happen every day, regardless of race, creed, color, or social strata, though children of color and those living in low-income housing have been affected most.

Advocacy groups, philanthropic organizations, and federal, state, and local governments have done much to educate the public about lead hazards—a herculean task. NCHH and its allies in this war on lead poisoning have also made great progress over the last 40-plus years. The studies we and our partners have done, the research we’ve provided, the articles we’ve written, and our advocacy efforts have resulted in a significant reduction in the number of Americans with elevated blood lead levels, as well as medical treatment for those affected. We’re proud of our work, and we’re proud of all the others who’ve joined us in the fight.

Now we need for you to join us as well, and we need you today. NCHH and the National Safe and Healthy Housing Coalition have just created a petition entitled “Tell Congress to End Lead Poisoning Now” that outlines a comprehensive strategy to end lead poisoning within five years.

Take a few minutes to check out the petition. Now we want you to sign it. Yes, YOU. And then we want everyone you know to sign it as well, which means that we need you to share it with people you know and ask them to share it too. Sign it, share it, and change the world—just a little.

Some of you have probably already signed the petition. You read the title and said, “I’m IN!” (Thank you!) Maybe you’re in because someone in your family has been exposed to lead. Maybe there’s lead in your house or apartment right now, and you don’t have the money you need to make your home safe once and for all. Or maybe you know someone down the street, one street over, or someone who goes to school with your kids, who’s been touched in some way by lead poisoning. Maybe you know someone who’s sitting in jail, and you think that maybe his or her life would be completely different right now if only they hadn’t been exposed to lead.

But maybe you haven’t gotten around to signing the petition just yet. We know that some of you are thinking, I don’t know anyone with this problem or This isn’t really a problem for me. But it really is. Whether or not we realize it, we’re all affected by lead poisoning:
  • Because families move into older homes every day.
  • Because children attend older schools every day.
  • Because some kid visits his or her grandparents’ home every day.
  • Because water flows through old pipes every single day.
  • And because lead poisoning can lead to learning disabilities, impulse control issues, and violent behavior, we pay tax money to fund educational services, law enforcement efforts and the judicial system to fix lead-related problems after they’ve happened. 
We want to tell Congress to invest more in the system upfront so that problems don’t happen. It’s a sound investment in our collective future: The return on investment for lead poisoning prevention is estimated at no less than $17 for every $1 spent.

As NCHH’s David Jacobs and Amanda Reddy commented in a recent editorial, lead poisoning is preventable, and we know how to prevent it; but our investment has to be more widespread and sustained.

Help us tell Congress that it is time to end childhood lead poisoning. Won’t you help us to reach our goal of 20,000 signatures? Stand up and be counted: Please sign the petition right away and share it with your friends, associates, and family.

Hot Tips to Protect Your Home from Fires

We’ve all heard the phrase “where there’s smoke, there’s fire” at least once in our lives. Most of the time, that smoke is the only unfortunate warning we get before we realize something’s wrong. It’s easy to go through your home and make sure matches and lighters are put away and clothes aren’t near a space heater and then call it a day, but it takes a bit more diligence and work to protect your home from fires.

1.    Check Your Cords

Remember the episode of Friends when Rachel left her hair straightener plugged in and accidentally burned down Phoebe’s apartment? It’s true that leaving your electronics plugged in for a while can start a fire, but the same is true for faulty or deteriorating cords for those electronics. If the plastic covering on a cord is broken and the wires underneath are exposed, it could send sparks flying and start a fire. Make it a habit to check all of your electrical cords; if they’re frayed or broken, consider buying a new item to replace the potential danger. You can also use electrical tape (if the break is not extremely bad) as a temporary solution until you’re able to replace the cord. Also make it a habit to check your outlets to make sure they’re not overloaded. If you have to use an outlet for more than two plugs, use a power strip or surge protector. 

2.    Clean the Oven

Almost every movie and TV show we’ve seen shows fires always starting in the kitchen. Ovens, toasters, microwaves, and even the refrigerator can be potential sources for a fire. Keeping everything clean and free of debris will lessen the risk of starting a fire. If you use pot holders, towels, or paper towels in the kitchen, keep them clear of the oven burners so they don’t catch fire. Cleaning your stovetop and oven to prevent or get rid of the grease buildup also makes it harder to fires to start spontaneously. Lastly, always check the kitchen appliances before you go to bed: make sure all burners are switched off and unplug toasters and toaster ovens if you won’t be using them. Make sure that you also have an unexpired fire extinguisher near the kitchen, preferably one that is designed to put out grease fires. 

3.    Keep an Eye on Your Candles

Candles are some of the most useful home accessories: They can light a dark area, fill a room with delicious fragrance, and even serve as a prop for telling spooky stories. At the same time, candles are some of the most dangerous home accessories. You should never leave a candle unattended, especially when there are children around. Don’t leave candles burning around loose fabrics like curtains or clothes, and always extinguish the candles when you’re finished with them. Rest candles on a sturdy surface that won’t fall over. If you absolutely have to leave a candle (maybe you need to step into another room, for example), move the candle to a tall and safe space where it won’t be at risk of falling or being bothered.

4.    Avoid Smoking in the House

As tempting as it may be, it’s really a good idea to take your cigarettes outside if you must smoke. You’ve no doubt heard stories about people falling asleep with lit cigarettes, which is obviously very dangerous. On a related note, you don’t want to leave cigarettes, matches, and lighters around the house where kids can get to them.

5.    Stack Your Firewood Correctly

A wood-burning fireplace can be quite cozy in the winter time, but if you aren’t careful, it can also be dangerous. You’ll want to avoid embers flying out onto your carpet, which can be done by stacking wood correctly. If you stack your wood as you would a bonfire, you can reduce your chances of embers popping out into your living room. Also, if you burn pine, hemlock, or other evergreen wood species, have your chimney cleaned regularly. These wood types contain more tar, which can result in a creosote buildup in your chimney. Never operate a fireplace without a screen, and never leave a fire unattended.

6.    Clear the Flammable Debris

Wildfires are just as dangerous as a kitchen fire, depending on where you live. Dry brush and sweltering heat is just enough to cause a massive outdoor blaze. You can protect your home by clearing out dead branches and leaves from around the outside perimeters and composting them instead of burning them. If you have trees around your home, trim any branches that look dead and are hanging over the house to prevent a flame from dropping onto your roof. If you have firewood by your back door, consider moving the piles away from house once the hotter months start coming back. Firewood piles can easily catch a spark and go up in flames, and a pile of lit firewood by your home can mean disaster or the need for major restorations.

7.    Get the Proper Smoke Detectors and Replace Them Every 10 Years

It goes without saying that you should have smoke detectors in your home, but many people assume that they’re all basically the same. Smoke detectors with photoelectric sensors are faster to respond to smoldering fires and are recommended by the International Association of Fire Fighters. Ionization detectors are better suited for flash fires; however, they’re more likely to alarm for non-life-threatening situations such as burnt toast. This can be a disadvantage of the dual-sensor detectors as well. The National Fire Protection Association (NFPA) recommends installing both ionization and photoelectric alarms in your home for the best overall protection from both sudden and smoldering fires. If you’ve decided to replace your ionization detector for a photoelectric model, don’t discard a working smoke detector until you have and are ready to install its replacement. Having a working detector is more important than having a specific variety.

While we're talking about smoke detectors, the best protection comes from having a smoke detector with a 10-year battery, and from replacing that smoke detector after 10 years. It’s may seem inconvenient, but it’s worth it to keep your family safe.

The good news is that it’s not difficult to keep your home safe from fires. You just need to be aware of the dangers and take the appropriate precautions.

Patricia Sarmiento loves swimming and running. She channels her love of fitness and wellness into blogging about health and health-related topics at She played sports in high school and college and continues to make living an active lifestyle a goal for her and her family. She lives with her husband, two children, and their shih tzu in Maryland.

Photo by tpsdave via Pixabay.

The Family that Smokes Together

Before Dad was a physician, he was a smoker. And, because we lived in his house, we were smokers too.

Throughout my life, people have thought it odd that a doctor could also smoke, but it’s not really so strange because Dad started his habit at 14. He was already a veteran of smoking before he ever set foot in med school, and any doctor will tell you that med school is incredibly stressful—it’s not the best environment for quitting anything, except maybe sleep. Plus, he enjoyed it. These were the days before the Surgeon General’s package warnings, the terrifying ads, and the lawsuits. By 1966, when the warnings started appearing on cigarette packaging, he’d already spent half of his time on Earth as a smoker.

As kids, my sister and I waged a failing war against the cigarettes: We begged and pleaded, we pinched our noses and remarked about the horrible smell. We hid the packs and the ashtrays. I’ll bet many of you did the same things to your parents. One time I even “loaded” a cigarette, which resulted in a small explosion that angered Dad, not because he was surprised by it but because the cinders nearly burned his shirt. But every time we tried, he proved that his love of smoking was somehow stronger than we were.

For a year or so, he smoked a pipe. The pipe smoke smelled better than the cigarettes, but it was still smoke that wafted through the halls.

So we grew up with smoke in the house every morning before, during, and after breakfast. Some people wake up to the aroma of eggs or bacon, but we woke to the acrid odor of cigarettes. The other thing I woke up to almost without fail was a lump in the back of my throat—an actual lump of gunk that accumulated there while I slept. Part of my morning routine was to get up and expel a gob of phlegm into the sink. It didn’t end there, either—several times a day I repeated this ritual, right up until bedtime. Every day, for years.

My mother thought it was disgusting, and she told me so. I agreed, but what was I supposed to do about it? “I gotta get it out somehow,” I said grimly as I continued to hack away.

Now, you’d think from this description that my house was absolutely hazy with smoke all the time, but it wasn’t. Dad had very long hours throughout the week and when he was away, we didn’t notice any lingering smell.

Something unexpected happened when I left for college. Within a few weeks, my coughing subsided. A few more, and it ended altogether. Honestly, I hadn’t noticed it happening, probably because it was so gradual and because I hadn’t made any conscious changes to my lifestyle. I only noticed it when I woke up on the first full day of my fall break. The lump in my throat was back, which must’ve meant that it had stopped sometime while I was away. My mother heard me and commented again about the horrible noise and what a disgusting habit it was. I told her that no one was more disgusted by it than I, but it was funny because this morning was the first time I’d done it in a long time—there must be something in the house that was making me sick.

It wasn’t long after that I started hearing about the dangers of secondhand smoke. Secondhand smoke is the smoke that the other people in the presence of a smoker breathe, the smoke that my father expelled from his lungs after every drag from his cigarettes or puff from his pipe as well as the smoke that rises from these tobacco products as they burn. In short, it’s what my sister and I complained about for roughly 20 years. All the things that can happen to a person as a result of smoking can happen to a nonsmoker too if they’re exposed to secondhand smoke. Secondhand smoke is a known trigger for people with asthma and can lead to lung cancer, too.

You may not have heard of it, but there’s also a thing called “third hand smoke,” which is the chemical residue left behind on surfaces that we take into our bodies by touching contaminated surfaces, ingest from hand-to-mouth contact (or possibly via our food), or breathe in as dust after the actual smoking stops. These would be the chemicals trapped in curtains, on wallpaper or painted surfaces, or the foul odor you detect in a smoker’s car. Whatever you smell in the car is the particulate residue of various chemicals including carbon monoxide, arsenic, butane, lead, toluene, and hydrogen cyanide. If you’ve spent any time on our website at all, you may already know how dangerous carbon monoxide and lead are. Butane is used in lighter fluid and  fuel for camping stoves, and toluene is found in paint thinner. Anything with a name like “hydrogen cyanide” can’t possibly be good for you; this substance is used in chemical weapons. If that’s not frightening enough, polonium-210 is a radioactive carcinogen (meaning it can cause cancer). And arsenic is, well, arsenic. That’s what you’re taking into your lungs when you’re breathing second- and third hand smoke. And before you say anything about air fresheners, forget it: They’re masking the chemical smell, not removing it; you’re still breathing smoke residue and to it you’ve added other chemicals blended to smell like pine or vanilla.

Sure, it’s your life—you can do what you like with it, but what about your family and your friends? Are their lives yours too? And what about your pets? Does old Rufus have to suffer because you don’t feel like quitting? He might be “man’s best friend” to you, but if he knew what you were doing to him, he might not hold you in the same regard. So, if you're a smoker, why not quit? If not for yourself, then how about for your family? And if you’re not willing, or haven’t been able to break the habit, at least take it outside.

As for my own Dad, well, he finally did stop. It happened after he spent a month on the ventilator after a surgery, a procedure that followed angioplasty and an open-heart bypass. His lungs were really weak. When he finally left the hospital, roughly 20 days later than expected, he realized that he was never going to wake up from the next surgery at all if he kept smoking. All of the surgeries he'd endured might've been avoided had he not smoked or even if he’d quit sooner. Suddenly, smoking seemed to be a lot less enjoyable to him, and so he quit—at age 60—but he’d done too much damage to his body. He was already suffering from emphysema by then and often used an oxygen pump to assist his breathing. Still, I think quitting did allow him to live a longer life, and he got to meet his first grandchild before he passed.

Democrats Add Eliminating Lead Poisoning to Party Platform

On July 9, 2016, history was made: A major U.S. political party added the words "we must make it a national priority to eradicate lead poisoning" to its platform. Never in the history of American politics has a major party called for the elimination of lead poisoning explicitly as a portion of its platform.

That finally changed late Saturday night as the Democratic Platform Committee approved Amendment 176 to add the following language to their platform:

"Democrats believe we must make it a national priority to eradicate lead poisoning which disproportionately impacts low-income children and children of color and can lead to lifelong health and educational challenges, as a public health threat. We will prioritize hiring and training workers from affected communities to clean up toxic brownfields and expand clean energy, energy efficiency, and resilient infrastructure."

As a nonpartisan organization, NCHH hopes that all of the political parties will recognize the importance of this provision and add it to their respective platforms. The health, safety, and well-being of America’s children is important to all Americans.

Kudos to platform committee members Mara Keisling and Mary Kay Henry, President of the Service Employees International Union (SEIU), for promoting and offering this amendment. 

Watch a video of the amendment's introduction by Mara Keisling and its subsequent approval here.

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